Basic Information
| Provider Information | |||||||||
| NPI: | 1336268770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOVASCULAR PERFUSION ALLIANCE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12815 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731572815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 N MAY AVE | ||||||||
| Address2: | STE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731126641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | POOR | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | DEWAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4056045613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | LP24 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.